Adolescent Suicide

School Based Suicide Prevention Programs

Background

The goal of school based suicide prevention programs are to: increase awareness, promote identification of students at high risk of suicide and suicide attempts, provide information to students, teachers and parents on the availability of mental health resources, and enhance the coping abilities of teenagers (Zenere and Lazarus, 1997).

In some states, such as California, school-based suicide prevention programs have been mandated by law. These programs are aimed at sensitizing students and staff to the risks of suicide and the "warning" signs of suicide in adolescents: suicide threats or other statements about a desire to die, previous attempts, marked changes in behavior, making arrangements to say goodbye. These programs include both curricula components to teach students about these warning signs and what to do, as well as non-curricula components such as peer groups, hot lines, intervention services and parent training. Unfortunately, we could find no evaluations of these interventions. There is also some suggestion that discussion of suicide with youth can initiate imitative behavior and actually increase the risk of suicide.4

There is relatively little evaluation of school based programs which includes suicide or suicide attempts as outcome measures. We decided not to include studies in which the only outcome measure was change in students' knowledge, attitudes and beliefs since there is no information on how well these correlate with actual risk of suicide. We found five studies to review. None of the studies was a randomized controlled trial. All studies were ecological.

Review of school based suicide prevention programs:

Author

Metha et al, 1998

Study design and target population

US population. Ecological design.

 

Intervention

State policies regarding school based suicide prevention programs.

Outcomes

Suicide rates between 1979-1994.

Results

19 states had adopted legislation regarding youth suicide prevention. In 4 states, the laws specifically mandated a school curriculum.

ANOVA revealed a decrease in suicide rates over the study period but no relationship to any state program.

Study quality and conclusions

National study but weak design.

Not clear what ages the data were on.



Author

Zenere & Lazarus, 1997

Study design and target population

Dade County Public Schools.

Time series before-after design..

Intervention

Three tiered approach of prevention intervention, and post-vention services in schools, started in 1989.

Outcomes

Suicide attempts and completed suicides.

Results

Number of completed suicides dropped by 63% from an average of 12.9 per year (1980-1988) to 4.6 per year (1989-1994)..

Suicide attempts decreased from 87 per 100,000 students (1989-1990) to 31 per 100,000 (1993-1994).

Study quality and conclusions

Before after study without a non-intervention control group is a weak design.

Multifaceted program involving teachers, students, and parents.



Author

MMWR, 1998

Study design and target population

Western Athabaskan American Indians in New Mexico.

Intervention

School based "natural helpers", community education, crisis intervention, implemented in January 1990.

Outcomes

Rates of suicidal acts: suicide attempts and completions.

Results

Rates of suicidal acts in 15-19 year olds decreased from 59.8 per 1000 before (1988-1989) to 8.9 per 1000 in 1990-1991 and 10.9 in 1996-1997. This is an 82% reduction.

Study quality and conclusions

Before after study without a non-intervention control group is a weak design..

Multifaceted program involving teachers, students, and parents.



Author

Wiegersma, et al, 1999

Study design and target population

Secondary schools in the Netherlands.

Design: mixed ecological.

Intervention

Open consultation hours for adolescents in school based clinics.

Outcomes

Comparison of rates of suicide mortality for 15-19 year olds; hospital admissions for suicide attempts among 15-19 year olds in areas that had open consultation hours to those which did not.

Results

Adjusted Odds Ratio for suicides in areas with vs. without consultation was 0.98 (95% CI 0.69, 1.18).

Adjusted odds ratio for admission for suicide attempts was 1.30 (95% CI 0.97, 1.75).

Study quality and conclusions

No effect of providing open consultation hours for teens in schools on suicide attempts or completions.


Author

Leisenring, 2000

Study design and target population

15-18 year olds in 4 rural Vermont counties.

Design is mixed ecological.

Intervention

School/community based intervention.

Begun in March 1988.

Outcomes

Suicide rates in 1982-1987 before the intervention compared to 1988-1993 after the start of the intervention in the 4 target counties compared to 4 control neighboring counties.

Results

Suicide rates in the intervention counties decreased by 73% compared to 41% in the control counties.

However, in a regression analysis, this was not significant.

Study quality and conclusions

There was an effect although it was not significant. There were only 4 counties however, and 8 suicides pre and 2 post. Thus, the power of the study was low.


Author

Kalafat, 1997

Study design and target population

Mixed ecological design.

15-24 year olds in New Jersey.

Intervention

School based Adolescent Suicide Awareness Program first implemented in 1983-1984 in Bergen County, NJ..

Outcomes

Suicide rates for 15-24 year olds in Bergen Co. compared to whole state.

Results

Rates in Bergen County decreases by 40% between 1978-1982 and 1988-1992 compared to 9% decreases in NJ as

Study quality and conclusions

Some evidence but not much information about evaluation..

Summary of school based suicide prevention program studies

These studies show possible substantial effects of school based programs. The reductions in injuries range from 40-80%. These are quite large. However, none of these were RCTs and they all used weak study designs.

Recommendations

There is no evidence from these studies that school based suicide prevention programs were harmful, i.e. no studies found an increased rate of suicide or attempts associated with introduction of the program. However, the evidence for their effectiveness is weak. We recommend that a large scale, rigorous randomized controlled trial of these programs be conducted.